A Systematic Review of Conservatively Managed Isolated Extra-Articular Proximal Phalanx Finger Fractures in Adults

SUMMARY Study design Systematic review Background Proximal phalangeal fractures of the hand are challenging to treat, and significantly impact hand function and quality of life if poorly managed. Purpose A systematic review to determine the efficacy of conservatively managed extra-articular proximal phalanx fractures to optimise recovery and prevent the need for surgical intervention and its associated risks. Methods A literature search that included variations of the phrases ‘proximal phalanx’, ‘fracture’ and ‘conservative management’ was performed on 17 December 2023 using seven electronic databases and trial registries. Article screening, data extraction and critical appraisal using the Structured Effectiveness Quality Evaluation scale was performed independently. Results Seven studies that captured 389 fractures from 356 unique patients were included. Studies were of level II to IV evidence and included one comparative cohort study and six prospective case series. Interventions involved timely rehabilitation, a plaster or orthotic device, controlled metacarpophalangeal joint flexion and free mobilisation of the interphalangeal joints. A weighted mean total active motion score of 249° was achieved, with 99.5% (387/389) of fractures achieving union. Conclusions This systematic review cautions against definitive recommendations on conservative techniques for managing proximal phalanx fractures due to limitations of the available literature. However, our findings tentatively supports non-operative approaches as an alternative to surgery.


a b s t r a c t
Study design: Systematic review Background: Proximal phalangeal fractures of the hand are challenging to treat, and significantly impact hand function and quality of life if poorly managed.Purpose: A systematic review to determine the efficacy of conservatively managed extra-articular proximal phalanx fractures to optimise recovery and prevent the need for surgical intervention and its associated risks.Methods: A literature search that included variations of the phrases 'proximal phalanx', 'fracture' and 'conservative management' was performed on 17 December 2023 using seven electronic databases and trial registries.Article screening, data extraction and criti-

Introduction
Fractures of the proximal phalanx (P1) constitute approximately 20% of all finger fractures, 1 and pose a unique challenge in clinical management. 2 If improperly addressed, these fractures can have a profound impact on hand function and overall quality of life.The complexities commonly arise from proximal interphalangeal joint (PIPJ) stiffness, often attributed to tendon adhesion and skeletal deformity.Displaced P1 fractures present distinctive challenges, manifesting as palmar angulation owing to interossei muscle insertion at the P1 volar base and hyperextension of the distal fragment from the central slip acting on the middle phalanx base. 3 , 4Given the crucial role of the P1 volar shaft surface in forming the flexor tendon sheath floor, achieving anatomical reduction becomes paramount for optimising flexor tendon glide.
The goal of P1 fracture management is to achieve a well-aligned, pain-free and stable digit with good range of motion (ROM) to provide functional movement. 3This requires an early motion program that ensures tendon gliding and joint mobility, while providing skeletal stability through conservative or surgical means.
Conservative approaches stabilise fracture fragments using soft tissue and are recommended for stable fractures. 4Freeland et al. 3 described an orthosis with dynamic finger positioning at rest or immobilised with the metacarpophalangeal joints (MCPJs) supported at 50-70 °flexion and the PIPJ supported at 0-15 °flexion to minimise joint contracture.This position also enables intrinsic muscle relaxation and the extensors to act as a tension band over the P1 for stability.Active motion further compresses the fracture site and stimulates periosteal callus formation to reinforce the injury site. 3 , 5n contrast, surgery is traditionally indicated for unstable fractures or if deformity recurs after closed reduction.This additional 'planned injury' risks secondary scar formation and devascularisation of fracture fragments, 3 leading to tissue adhesion and joint contracture.Thus, the benefit of increased biomechanical stability through surgical incision, risk of stiffness and delayed healing need to be considered.

Purpose of the study
Despite the proven outcomes of conservative P1 fracture management, surgical fixation remains commonly recommended in the literature, particularly in open or unstable fractures with or without intra-articular involvement, rotational deformity or significant displacement. 6 , 7This systematic review seeks to provide evidence that supports conservatively managed extra-articular P1 fractures to optimise recovery and mitigate the necessity for surgical intervention and its associated risks.

Methods
A protocol was registered on the PROSPERO international prospective register of systematic reviews (CRD42021270244) and performed according to the Preferred Reporting Items of Systematic Reviews and Meta-Analysis Protocols statement. 8rticles were sourced from database inception until 17 December 2023 from MEDLINE, Embase, Emcare using Ovid; trial registries (World Health Organization International Clinical Trials Registry Platform, Australian New Zealand Clinical Trials Registry and ClinicalTrials.gov)and the Cochrane Central register of Controlled Trials, using their respective websites.
A search strategy was designed with a clinical librarian using phrases and Medical Subject Headings (MeSH) related to 'proximal phalanx', 'fracture' and 'conservative management'.Variations of these terms were tailored for each database (Supplement Table 1).No study setting or publication status restrictions were imposed.Attempts were made to obtain translations for publications in languages other than English.

Selection of studies
References were imported onto Covidence to filter duplicates and facilitate screening.Five reviewers (MZ, JH, MH, TC and SN) independently short-listed all studies by screening titles and abstracts according to the eligibility criteria ( Table 1 ).Articles were excluded if they were unrelated, or an English version of the full text could not be obtained.Disagreements were resolved through group discussion with all five reviewers to finalise the selection.
Authors were contacted if the data necessary to assess eligibility according to the above criteria was missing in their manuscript.Articles were excluded if authors failed to reply after two attempts of contact.

Data extraction and management
As per the Cochrane Handbook of Systematic Reviews of Interventions, 9 three reviewers (MZ, JH and TC) independently gathered data on study design, demographics, fractures, intervention, followup and outcomes.The primary outcome measure of interest was mean post-intervention ROM of any included finger joint.Secondary outcome measures included fracture union, pain, satisfaction, grip and pinch strength, return-to-work data and complications.
Outcomes for mixed population studies were recalculated if the population of interest was distinguishable from the gross data set.The weighted mean for outcomes of interest was calculated by multiplying each value with its corresponding sample size, summing these products and then dividing by the total of the sample sizes.This information was tabulated using Microsoft Word.
Five reviewers (MZ, JH, MH, TC and SN) independently assessed the study quality of all short-listed articles using the Structured Effectiveness Quality Evaluation Scale (SEQES), 10 which scores interventional studies from 0-48 using 24 criteria relating to objectives, study design, participants, intervention, outcomes, analysis and recommendations.Disagreements were resolved by discussion with all five reviewers.A meta-analysis was deemed inappropriate owing to study designs which were heterogenous and of low-moderate quality.A narrative synthesis is therefore presented.A treatment protocol was synthesised by consolidating the common intervention characteristics across all included studies.

Results
An extensive literature search was conducted which yielded seven studies 4 , 11-16 ( Figure 1 ).Study quality on the SEQES 10 ranged from 14-33 out of a possible 48 ( Table 2 ).One study 13 was graded level II according to the Oxford Centre for Evidence-Based Medicine, 17 as it used a randomised comparative approach.The remaining studies were case series and designated level IV. 4 , 11 , 12 , 14-16

Interventions
Table 4 highlights the variability in the orthotic material used, joint positioning and exercise programs.

Follow-up
The six studies 4 , 11-14 , 16 that reported the mean follow-up time found a weighted mean of 8.3 months (3 weeks-69 months) as detailed in Table 5 .
The approach to assessing ROM varied from calculating TAM scores 18 (subtracting the total extension deficits of the MCPJ and IPJ from the sum of their active flexion) to using scoring systems as detailed in Table 6 .
• The Reyes criteria was used in three studies. 4 , 11 , 15Among the 29 patients in Reyes and Latta's study 15 assigned to 6-month follow-up, 86% midshaft fractures and 39% base fractures had 'excellent' outcomes.The remaining 47 patients with 6-week follow-up achieved 'excellent' and 'good' outcomes in 68% and 59% of fractures, respectively. 15'Excellent' outcomes were also found in 100% of patients in the study by Rajesh et al. 4 and 95% in Byrne and colleagues 11 trials.• Thomine et al. 16 used the SOFCOT 19 criteria and found that 43% patients achieved 'good' outcomes.
• As for the studies not using a scoring system, Figl et al. 12 found that 86% of cases returned to full ROM after conservative management.Franz et al. 13 found no significant difference in finger TAM between the plaster and LuCa cast groups.
Regarding secondary outcomes, it was found that all but two fractures achieved union with conservative management.Two studies reported mean return-to-work timeframes of 12 weeks 4 and 44 days. 16

Complications
Reported complications included anatomical deformities such as loss of reduction, malunion, shortening or misalignment and functional abnormalities such as joint stiffness and swelling.Among the 389 total fractures, there were 50 cases 13 , 15 , 16 of malalignment, 53 cases [12][13][14] of extension deficits and 14 cases 4 , 16 of shortening up to 3 mm.Seven patients required surgical intervention owing to loss of reduction. 11 , 13 , 14There were also two cases of complex regional pain syndrome.

Discussion
This review outlines the evidence for conservative modalities for extra-articular P1 finger fracture management, including those which are initially displaced or unstable, finding among other results that a treatment algorithm (as depicted in Figure 2 ) could achieve union in close to 100% (387/389) of fractures.
'Excellent' or 'good' ROM outcomes were achieved in 87% and 95% of fractures, respectively, 4 , 11 , 15 with a weighted mean TAM of 249 °, 4 , 11 , 13 providing 96% of normal TAM. 20This result is also comparable to surgical fixation, highlighting how even oblique, spiral or complex fractures that are inherently unstable can be managed non-operatively provided that adequate reduction can be achieved and maintained. 21his is the first systematic review to the authors' knowledge which provides a focused overview of conservatively managed extra-articular P1 fractures in adults, and supports previous studies in this  All studies reported good results in mobility with a mean TAM of 240 °to 258.9 °, demonstrating conservative treatment as a viable alternative to surgery; similar to the mean TAM of 249 °found in this review.A systematic review by Verver et al. 21in 2017 examined the treatment options for proximal and middle phalangeal fractures, comprising 16 studies and over 381 P1 fractures, 117 of which were managed non-operatively.It concluded that P1 fractures, even those which are initially unstable, have the potential to be treated without surgery and achieve good functional outcomes.The various management strategies explored in the included articles are summarised into a treatment protocol in Figure 2 , with an example of a custom-made thermoplastic hand-based orthosis with buddy taping depicted in Figure 3 .A variety of orthotic designs were used, with common features including the MCPJs positioned in 70-90 °or maximum flexion; 4 , 11 , 14 neighbour/buddy strapping 13 , 14 , 16 or finger stalls 11 , 12 .Splint designs varied in their incorporation of all digits 12 , 14-16 or only the affected and adjacent digits, 4 , 11 thereby limiting unnecessary immobilisation.The IPJs were free to mobilise in all studies. 4 , 11-16Using MCPJ flexion and active IPJ motion, the deforming forces of the intrinsic muscles on the P1 fragment are reduced, allowing the extensor mechanism to envelope the P1 and apply compressive forces across the fracture site.
Orthoses were either hand- 4 , 11 , 13 or forearm-based, 13 , 14 , 16 with one study offering a direct comparison. 13Franz et al. 13 found no statistical difference in mean TAM or wrist motion at 12 weeks, suggesting potential for using less restrictive and more comfortable orthotics without compromising safety.Patients who were allowed free wrist mobilisation were noted to have increased wrist ROM initially and higher patient satisfaction. 13uddy strapping 11-14 , 16 as an adjunct to orthotic intervention provides analgesia and encourages finger tracking during exercise to prevent secondary displacement.Finger buddy stalls have the added benefit of reducing oedema. 11 , 12Interestingly, paediatric studies 23 , 24 have suggested buddy taping alone can be effective in treating stable fractures if used judiciously, although has yet to be studied in adults.The material used for orthosis construction varied from plaster, synthetic casting material (e.g., fiberglass), thermoplastic and metal.Orthoses were worn full-time for three to four weeks, with some authors 4 , 12 , 13 extending the wear time by two to three weeks if there were concerns regarding fracture healing.
All studies aimed to achieve bony healing and free mobility simultaneously by encouraging patients to actively flex and extend their IPJs as early as possible, with or without a formal hand therapy program.This allowance for free IPJ motion underpins the functional approach to conservative P1 fracture management, avoiding immobilisation and delayed motion which are the greatest predictors of poor outcome. 25

Clinical implications
Due to limitations of the included studies, offering conclusive recommendations should be cautioned against.This review highlights the potential to shift the management of P1 fractures, which would have been traditionally managed surgically, into the procedure room or clinic, while maintaining comparable functional outcomes.
Although the operating theatre provides certain advantages such as a controlled sterile environment and the availability of regional or general anaesthesia, it is associated with significant costs to the healthcare system and the patients and broader community.In 2012, de Putter et al. 26 conducted a study in the Netherlands which found hand and wrist injuries to be responsible for $740 million in costs, making it the most expensive injury.$329 million was attributed to funding healthcare resources such as surgical staffing and procedural time, equipment and internal or external fixation systems, 26 while, $411 million was attributed to lost productivity from absenteeism and reduced work capacity, largely secondary to the demographic of these injuries being men of working age, which is reflected in this review. 26onservative management has demonstrably fewer complications and allows bone healing and rehabilitation to occur simultaneously, 3 , 4 allowing the patient to resume work sooner 14 and minimise the societal financial-economic burden.It also reduces the adverse consequences associated with surgery and anaesthesia such as adhesions or risk of infection.Although at present there is no study to the author's knowledge that has provided a cost-benefit analysis comparing operative fixation with conservative techniques for P1 fractures, a 2018 American study by Garon et al. 27 on metacarpal and phalanx fractures indicated that performing closed reduction and percutaneous pinning in the procedure room reduced costs by 63.2% without an increase in complication rates.Therefore it is important, to treat P1 fractures using conservative modalities whenever it is appropriate and feasible to do so.

Limitations
Limitations of this study are similar to those identified in two previously published reviews. 21 , 22he included articles had significant variability in study design and poor reporting quality.The orthotic design and duration of wear differed greatly between studies, often with little justification.Additionally, despite being integral to maintaining the position required for fracture alignment and healing, adherence to orthosis wear was not formally measured in any study.Finally, studies varied in their enforcement of hand therapy, and lacked detail regarding the exercises used.Significant heterogeneity existed in the criteria used to assess treatment outcomes, as well as when and how these parameters were measured.Although several studies reported goniometry measures, no uniform criteria were used.This is evidenced in studies that assessed patient outcomes using multiple scoring systems, such as in the study Rajesh et al. 4 where all cases achieved 'excellent' outcomes as per Reyes's criteria, but only 72% of cases were graded 'excellent' according to Belsky's criteria.The variation in reporting highlighted a lack of consensus as to which parameter accurately represents meaningful results.Despite most studies including various radiological outcomes, no study assessed the significance of these findings on the quality of life or socioeconomic impact of time off work, treatment costs and lost productivity; despite functional mobility and patient satisfaction not being mutually exclusive with residual radiological or clinical deformity. 12The variation in follow-up time, ranging from three weeks to 69 months, also makes it difficult to draw comparisons as outcomes such as complications or treatment failure can be missed in shorter follow-up periods.

Recommendations
There is currently a paucity of high-quality data to facilitate evidence-based treatment decisionmaking.Future studies would benefit from large population comparisons between surgical and nonsurgical techniques, and different conservative therapies.There needs to be adequate blinding for comparison, as well as structured and transparent treatment regimens and assessment protocols.Although some comparative prospective trials have been performed, they are limited by small sample sizes 28 or include paediatric patients 29 which may confound the results.Future trials should assess details regarding total therapy time, rehabilitation modalities and timing, and socioeconomic costs.Qualitative surveys to elucidate the patient perspective of conservative and surgical options should be encouraged, as should the inclusion of a wider range of standardised outcomes which are more function-and patient-focused, as recommended by the International Consortium for Health Outcomes Measurement 30 to assist in providing more holistic patient care.Some of these suggestions are currently being addressed in a single-centre prospective trial at Austin Health in Australia by Cole et al. 31 that is assessing the benefit of conservatively treating P1 fractures which would have conventionally been managed surgically, and a large (n = 400) multicentre randomised trial by Karantana and colleagues 32 in the United Kingdom comparing surgical treatment with orthotic intervention.

Conclusions
This systematic review included low-moderate level prospective case series with varying outcome measures; hence, it would be erroneous to provide definitive recommendations regarding the efficacy of conservative techniques in managing extra-articular P1 fractures in adults.Despite this, our study provides a weak recommendation that non-operative therapies for rehabilitating hand function following extra-articular P1 fractures with three to four weeks wearing an orthosis or plaster with

Figure 1 .
Figure 1.PRISMA Flow Diagram representing the search and selection of studies assessing the efficacy of conservative therapies for proximal phalanx fractures.

Good: Mobility > 10 -
80 °Fair: Mobility > 25-75 °Poor: Mobility > 30-70 °Other findings N/A Flexion loss > 1 cm from the tip of the finger to the palm demoted the patient to the immediate inferior group N/A Note.PIPJ = proximal interphalangeal joint; TAM = total active motion domain.A recent scoping review by Vervloesem et al. 22 in 2023 identified current methods of rehabilitation following conservative and surgical methods of management for extra-articular P1 fractures.It included 267 fractures from eight articles, five of which examined conservative interventions.

Figure 3 .
Figure 3. Example of custom-made thermoplastic hand-based orthosis with buddy taping produced by the authors, with permission obtained from patient for publication purposes.

Table 6
Functional score comparison.